Prescription Drugs – Rx

How do I know if my Rx – Prescription is in the formulary – #Covered?

1st What is a Formulary – definition?

The formulary list of preferred Generic and Brand Drugs maintained by the Insurance Companies Pharmacy & Therapeutics Committee. It is designed to assist Physicians in prescribing Drugs that are Medical Necessary and cost-effective. The Formulary is updated periodically. Benefits are available for Formulary Drugs. Non-Formulary Drugs are covered when the Insurance Company  or an external reviewer (see our appeals & grievances webpage) approves an exception request. ^{EOC page 110} *

If you are eligible for Medicare Part D Rx, there is a shopping tool that searches all the plans!  But, be sure to enroll in the link we give you, so that you get our assistance and consultation in the future.

So, go back and check out the FREE quote, click on details, compare up to three plans and see what the co pay is for tier 4

Click on plan details to get more information.

I will grant you that this is a LOT of work.

We can’t stress this enough, the BEST way to find out what YOUR plan covers is in your EOC Evidence of Coverage.

2nd best is our website, 3rd is the one we link to, as it’s a popular plan in CA.

How to request a formulary #exception

• Check the EOC Evidence of Coverage.  Here’s Blue Shield’s as an example  procedure for Prior Authorization, exceptions & step therapy on page 71 of the EOC
• Oscar Pharmacy Clinical Guidelines  (Medical Necessity) We are showing Oscar as IMHO their guidelines are easier to read.
• Some drugs, most Specialty Drugs, and  prescriptions for Drugs exceeding specific quantity limits require prior authorization for Medical Necessity, as described in the Prior Authorization/Exception Request Process section. The Member or his/her Physician or Health Care Provider may request prior authorization
  • How to get prior authorization is on page 27
  • The Member, his/her Physician or Health Care Provider may request prior authorization by submitting supporting information
• For formulary exceptions, the prescriber’s supporting statement must indicate that the non-formulary drug is necessary for treating an enrollee’s condition because all covered  drugs on any tier would not be as effective or would have adverse effects, the number of doses under a dose restriction has been or is likely to be less effective, or the alternative(s) listed on the formulary or required to be used in accordance with step therapy has(have) been or is(are) likely to be less effective or have adverse effects. CMS.gov
• Once all required supporting information is  received, the Insurance Company  will provide prior authorization approval or denial, based upon Medical Necessity, within two business days.  Coverage requests for Non-Formulary Drugs in standard or normal circumstances will have a determination provided within two business days or 72 hours, whichever is earlier; the same requests in exigent circumstances will have a determination provided within 24 hours.
• Contacting your insurance company Check their EOC Evidence of Coverage., or the back of your ID card.
  • If we are your appointed agent, no charge, we can help you do this, if you send us the supporting documents from your doctor.
• Holistic alternative for erectile dysfunction to Viagra?

AI  Version of requesting formulary exception 

• Get a prior authorization: Your doctor must start this process by submitting a request to your insurance plan with a letter of medical necessity and supporting documents.
• Ensure the prescription is for an approved use: The plan will likely only cover Ozempic if it’s prescribed for a condition that it’s FDA-approved to treat, such as Type 2 diabetes. Coverage for weight loss alone is generally not provided.
• Provide detailed medical records: Your doctor should include notes, labs (like A1C levels), and any measurements (like BMI) to support the request.
• Document failed treatments: If you have already tried other, less expensive diabetes medications and they didn’t work or caused side effects, your doctor should include the dates, duration, and outcomes of those trials in the request. [1, 2, 3, 5, 6, 8]

• Filing an appeal: You have the right to appeal the decision if your plan denies the prior authorization.
  • Our webpage on appeals
• Building a strong case: Gather all documentation showing why preferred medications are not a suitable option for your specific medical needs.
• Using clinical evidence: In your appeal, you can include clinical research that illustrates why Ozempic would be more effective for your condition than the alternatives your plan prefers. [2, 5, 9]

Definition of Status of Rx in Formulary List

Definition of Restrictions